(As In Passport) Surname Passport No. Date of Birth D D M M Y Y Y Y Nationality Gender Male Female

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1 APPLICATION FORM POLITEKNIK UNGKU OMAR IPOH, PERAK DARUL RIDZUAN MALAYSIA Student s ID: Academic Session/Year: PROGRAME OFFERED (Tick Your Choice) 1. Diploma in Civil Engineering 2. Diploma in Electronic Engineering (Computer) 3. Diploma in Mechanical Engineering Passport-Sized Photo (3.5cm x 5cm) * Are you willing to accept a different programme from your choice above? (YES / NO) PART A PERSONAL DETAILS Incomplete information may delay the processing of this application. Please complete ALL sections in this form with BLOCK LETTERS (in BLACK ink only) Enclosed certified true copy of all documents required as listed in the APPLICATION CHECKLIST and sign the application form. Full Name (As In Passport) Surname Passport No. Date of Birth D D M M Y Y Y Y Nationality Gender Male Female Address Religion Marital Status Single Married Others Correspondence Address & Contact Details Guardian Address & Contact Details City Postcode City Postcode State Country State Country Tel. No. Mobile No. Tel. No. Mobile No. Name of Parents/Guardian Emergency Contact Name : Tel No.: Relationship: Address of Nearest Malaysia Embassy/Consulate at Origin Country PART B EDUCATIONAL QUALIFICATIONS 1. Institution Name of qualification Year School : City : State/Country : Page 1 of 7 PUO International Relations Unit

2 PART C DECLARATION AND SIGNATURE STUDENT S DECLARATION (NOTE: Please read the content carefully and make sure you understand what each paragraph means before signing it. This declaration form is a very important legal document and you should not sign it unless you agree with all the terms contained herein) 1. I understand and acknowledge that Politeknik Ungku Omar is the polytechnic where the search of knowledge is for the pursuit of excellence and where the development of personality as well as leadership character is of paramount importance. 2. I solemnly promise to: a) Uphold the ideals, philosophy and objectives of Politeknik Ungku Omar and lead a life of total commitment to the values of humanity, tolerance, honesty, hard work and good relationship with my fellows, colleagues, lecturers and Polytechnic staff. I shall also co-operate in the promotion of any atmosphere of peace and orderly behaviour within and outside the Polytechnic b) Abide by the Constitution, Statutes, Rules and Regulations including the Discipline of Students Rules and other documents framed by the Polytechnic Authorities from time to time. c) Maintain good behaviour in my relationship with other people in the Polytechnic and not to indulge in the abuse of drugs, immoral activities prejudicial to the good name of Politeknik Ungku Omar. d) Respect the identity and way of life of the Muslims as well as the way of life of non-muslims and believers of other faiths both in and outside the campus, and not to do anything that would tarnish the good name of Politeknik Ungku Omar. e) Observe decency and modesty in behaviour without imitating, introducing any undesirable and immoral trend or fashion. 3. I hereby declare that I agree to abide by Politeknik Ungku Omar Policies, Rules and Regulation at all time. 4. Failure to declare all the information mentioned will result in my application being rejected. I accept that Polytechnic shall have the right to reject my application. 5. I also understand that regular attendance is compulsory. Politeknik Ungku Omar is required by the Ministry of Education (MOE), Malaysia to report to the MOE, Police and Immigration if I am absent for 3 CONSECUTIVE DAYS without valid reason or prior permission from the Polytechnic. FINANCIAL DECLARATION 1. I agree and promise herewith to pay all fees owing to Polytechnic within the due date imposed, should my sponsor fails to settle them. I also agree to pay any late payment penalty or any other payment(s) related to the late payment as imposed by the Polytechnic. 2. I agree that the Polytechnic shall have the right to deduct from any scholarship / financial aid(s) given to me in order to settle part or all of any outstanding payments stated in (1) above 3. I agree that the Polytechnic shall have the right to demand any outstanding payments stated above from my Guarantors in the event that I leave Polytechnic before the completion of my course of study. 4. I also understand and agree that notwithstanding the completion or non-completion of my course of study, the Polytechnic can and will pursue / demand any outstanding payments owing to the Polytechnic after I have left the Polytechnic. I agree that the Polytechnic may engage any third party to collect on its behalf, any outstanding payments from me and thus I give my consent herewith for my relevant information to be disclosed to the said third party(s) by the Polytechnic. 5. I acknowledge and agree that the Polytechnic has the right to revise its internal regulations including its fee structures, whenever deemed necessary without any prior notification to be given. I agree to follow the revised / new regulations and fees accordingly. 6. i) I acknowledge and agree that I am providing valid contact information to facilitate any transactions during and after the completion of my study and I will update the Polytechnic should there be any changes. ii) If I do not claim for the refund of my deposit and any excess payment within one (1) year from my completion date and upon notification by Polytechnic to my updated address, I hereby consent to the said money to be given as: Donation to the Polytechnic Alumni Zakat Other Authorities, please specify.. 6. I hereby declare that all information in this form is complete and correct. I also agree to accept Politeknik Ungku Omar reserves the right to amend and add to existing policies, fees, rules and regulations as it deems fit. (NOTE: Any negligent misstatement shall result in the automatic cancellation of all concessions.) Signature of Applicant : Name of Applicant : Signature of Witness : Name of Witness : Page 2 of 7 PUO International Relations Unit

3 PART C DECLARATION AND SIGNATURE FINANCIAL GUARANTEE 1. I hereby agree to be the Guarantor of the student named: ID No:.. (Student s Name) during the period of the Course (Name of Course) at Politeknik Ungku Omar, Jalan Raja Musa Mahadi, 31400, Ipoh, Perak Darul Ridzuan, Malaysia. As the Guarantor, I hereby guarantee that I shall settle all outstanding debt incurred by the Student and (owing to Politeknik Ungku Omar) within the time specified. I also give my guarantee that the Student, shall: i) Complete his / her course of study within the time specified by Polytechnic and (ii) abide to the Constitutions of Polytechnic and its rules and regulations. If the Student is found to have breached any rules or regulations, I agree to pay damages and/ or compensation as demanded by Polytechnic or further legal action can be taken against me. 2. My personal particulars are as follows: i. Name : ii. Passport No : iii. Occupation : iv. Employer s Address : v. Office Telephone No : vi. Home Address : vii. House Telephone No : Total Monthly viii. Income : ANESTHETIC CERTIFICATION (NOTE: Complete this if the student is below 21 years old) International Relations Unit Politeknik Ungku Omar, Dear Sir / Madam I... (Parent / guardian s name), the parent/guardian of.. (Student s Name). (Student s ID) authorize you or your representative to sign on my behalf for treatment of my child, if he / she requires general or local anesthetic as advised by the medical officers appointed by Polytechnic. This permission is given in the event of an emergency as confirmed by the attending doctor, when required. I will absolve Politeknik Ungku Omar from any claims or responsibilities from any unfavourable consequences which may arise from the said operation. Signature of parent/guardian : Name of parent/guardian : Signature of witness : Name of witness : I hereby declare that all information given above is correct and true. If at any stage, any of the above information is found to be incorrect, Polytechnic authorities reserved the right to take any action against me Signature of guarantor : Name of guarantor : Signature of witness : Name of witness : NOTE: Qualified Guarantor: i. Immediate family members / Individual whose job is permanent and has a net income of not less than USD a month. ii. Financial Institution such as banks, and other government organization. Page 3 of 7

4 PART D STUDENT S PLEDGE STUDENT ID NO. PROGRAMME: I solemnly declare that during the period of my study at Politeknik Ungku Omar. a) I shall abide by the Laws of the country. b) I shall abide by the rules and regulations of the Polytechnic and any other rules and regulations made from time to time; c) I shall protect the good name of the Polytechnic at all times and look after the property and facilities from being destroyed by me or anyone else; d) I shall not be involved in any undesirable activity that will interfere with the administration and / or academic function of the Polytechnic. e) I shall devote my time to my studies and shall fulfil all academic conditions required. Student s Signature : Name : Signature of Polytechnic Officer : Name : NOTE: This form is to be signed during registration in the presence of the Polytechnic s official. Page 4 of 7

5 APPLICATION DOCUMENT CHECKLIST NO. ITEM QTY(Copies) TICK ( ) 1. PUO Application Form 1 2. Passport-Sized Photographs With BLUE Background (50mm [H] X 35mm [W]) 4 3. Copy Of Valid Passport (ALL PAGES) with certified pages in COLOUR (Including special pass and /or exit stamp, where applicable. 2 *Passport must be valid at least 15 MONTHS from the date of entry. 4. Academic Certificates/Transcripts in English with Certified True Copy* Pre-arrival Health Examination (origin country) 2 6. ORIGINAL copy typed or hand written Personal Bond Form Duty Stamped 1 7. Verification Letter From Scholarship / Study Loan / Sponsor (If Applicable) 2 * Please submit ALL of the documents to the International Relations Unit, Politeknik Ungku Omar (IRU, PUO) * Authenticated originals or certified true copies are required. If the originals are issued in a language other than English, English translation must also be submitted) FOR OFFICE USE ONLY NO. ITEM QTY (Copies) TICK ( ) NOTES 1. PUO Offer Letter 2 2. PUO Student Acceptance Form 2 3. Support Letter From JPP (Ministry of Higher Education Malaysia) 2 4. Payment Proof/Receipt/Transaction Slip i. Application Processing Fee 2 ii. International Student Services Fee (EMGS) 2 iii. Registration & Miscellaneous Fee 2 iv. Personal Bond 2 Application Received by: Receipt/Bank Draft No.: Date Received: Notification ed on: Recommendation/ Remark The Student s application is Approved Not Approved Student is granted to enrol for the Programme: Session / Semester offered: Reason if application is not approved Signature & Stamp : (IRU OFFICER) Date: Page 5 of 7

6 APPLICATION PROCEDURES STEP 1: CHOOSE YOUR PROGRAMME Please review the information in website and speak to our representatives for advice. Indicate the programme that you wish to apply. Take a look at the intake dates and decide on your preferred intake. STEP 2: CHECK ENTRY REQUIREMENTS Please check the entry requirements to ensure that you fulfil the necessary criteria for the programme you wish to apply. STEP 3: CHECK DOCUMENTATION REQUIREMENTS AND DATES Compile all the required documents to apply for the programme. All complete documents need to be submitted to International Relations Unit, Politeknik Ungku Omar (IRU, PUO) at least 12 weeks before the academic session begins. DOCUMENT CERTIFICATION REQUIREMENTS Certified duplicates of original documents, certified as exact reproductions, usually by the officer responsible issuing or keeping the original, or by a solicitor, notary public, justice of the peace or any other person authorized to take a statutory declaration. A certified document should display the stamp or seal of the certifier. All documents that are not in English should be accompanied by full English translated document that can be independently verified by Education Malaysia Global Service (EMGS). The original translation must contain: a) confirmation from the translator or translation company that it is an accurate translation of the original document; b) the date of the translation; c) the full name and signature of the translator or of an authorized official of the translation company; and the translator or translation company's contact details. Kindly ensure that you check the deadlines for submission at IRU, PUO website: STEP 4: SUBMIT APPLICATION FORM Please ensure that you fill up the Application Form completely and accurately. Please Courier, Fax or all the completed documents including Bank-In Slip / Telegraphic Slip as Proof of Payment. Kindly refer the CONTACT DETAILS. All international students who do not hold a Malaysian IC or a Malaysian passport must apply for student pass. An international student charge is compulsory and is non-refundable. Applicants holding Dependent Pass & Malaysia My Second Home (MM2H) visa are required to convert to Student Pass while studying at Politeknik Ungku Omar. STEP 3: CHECK DOCUMENTATION REQUIREMENTS AND DEADLINES PAYMENT DETAILS No. PAYMENT DESCRIPTION (New Student) AMOUNT (MYR) PHASE 1 1. Application Processing Fee PHASE 2 PAYABLE TO BANK ISLAM MALAYSIA BERHAD Koperasi Politeknik Ungku Omar WHEN TO PAY Upon submission of Application Form with all required documents. * Documents ONLY will be process once payment has been DONE **Applicant should /fax payment receipt as proof of payment Miscellaneous Fee Personal Bond (Varies by Country) 4, , BANK ISLAM MALAYSIA BERHAD Koperasi Politeknik Ungku Omar Upon Acceptance an Offer Letter 4. PHASE 3 Full Time Diploma Programme Tuition Fee (1 st Semester) i) Diploma In Civil Engineering 4, ii) Diploma In Electrical Engineering 4, AFFIN ISLAMIC BANK BERHAD Politeknik KPT Upon Receiving VAL/VDR iii) Diploma In Mechanical Engineering 4, PHASE 4 5. Arrival Medical Check-up (EMGS Requirement) Cash Upon arrival in Malaysia Page 6 of 7

7 STEP 5: CHECK STATUS OF YOUR VISA APPLICATION Once the Visa Approval application is approved by the Malaysian Immigration Department (MID), IRU, PUO shall and courier Visa Approval Letter (VAL) to the applicant. Airport Pick-Up Request International Relations Unit (IRU) provides airport pick-up service for newly arrived international students commencing his/her programme. Please inform the International Relations Unit TEN (10) working days prior to your arrival in Malaysia. Students from Single Entry Visa (SEV) required countries are responsible to bring the original Visa Approval Letter (VAL) together with passport to the nearest Malaysia Embassy/Consulate to obtain a single entry permit prior to entering Malaysia to avoid a fine or being turned back at the airport. All international students (except P.R. China) have to pay a personal bond, the amount of which is fixed by the Malaysian Immigration Department: The amount is totally refunded upon completion of the academic course if the student has not violated the rules and regulations of the Malaysian Immigration. Regular attendance is compulsory. It is regulation of the Ministry of Higher Education (MOHE) and Immigration Department that a student who is absent for 3 consecutive days without valid reasons or prior permission has to be reported to the Malaysian Immigration Department. Action may be taken which can result in the revoking of the Student Pass. BANK DETAILS Payment must be made via Electronic Funds Transfer (EFT)/Telegraphic Transfer / Bank Draft / Interbank GIRO) to: 1. MISCELLANEOUS FEES Bank Name : BANK ISLAM BERHAD Bank Swift Code : BIMBMYKL Payable To : KOPERASI POLITEKNIK UNGKU OMAR Account No. : Account Address : POLITEKNIK UNGKU OMAR JALAN RAJA MUSA MAHADI, IPOH, PERAK, MALAYSIA. 2. TUITION FEES Bank Name : AFFIN ISLAMIC BANK BERHAD Bank Swift Code : AIBBMYKL Payable To : KETUA AKAUNTAN KEMENTERIAN PENDIDIKAN MALAYSIA (KPM) Account No. : Account Address : DEPARTMENT OF POLYTECHNIC EDUCATION NOTES: *DO NOT SEND CASH OR CHEQUE. The full name of the applicant should be clearly printed on the reverse side of the bank draft. **Please Fax, Or Mail Bank In Slip / Telegraphic Slip As Proof Of Payment. Kindly Include the Students Name, Passport Number, Contact Number and Programme Enrolled to the Institution at Fax No: Or Via to irupuo@gmail.com CONTACT DETAILS Please Mail Or Courier The Application Form with Required Documents To: INTERNATIONAL RELATIONS UNIT (IRU) POLITEKNIK UNGKU OMAR, JALAN RAJA MUSA MAHADI, IPOH, PERAK, MALAYSIA. Tel : /7656 Fax : Website : irupuo@gmail.com Notes: Incomplete applications cannot be processed. Applicants are advised to submit their applications at least eight (8) weeks before the commencement date of the intake for sufficient time to process the student pass approval. You will be advised to study at the next intake if you submit your application less than 6 weeks of the commencement date. All rules and regulations are subject to changes (the Polytechnic reserves the right to change without prior notice). Page 7 of 7